I attended a conference last week organised by the Critical Psychiatry Network. The title of the day was Emerging Perspectives in Psychiatry. I thought it might be useful for this blog post to summarise some of the presentations during the day and add a few of my own reflections towards the end.
The Sanity of Madness: Some psychodynamic principles – Brian Martindale
This introductory talk represented a summary of a series of articles on psychodynamic thinking in relation to psychosis, published in the Royal College of Psychiatry’s continuing professional development journal, Advances in Psychiatric Treatment (APT), between January and July 2013 [e.g Martindale, B., & Summers, A. (2013). The psychodynamics of psychosis. APT, 19(2), 124–131 (RCPsych paywall)].
In psychiatric classification systems, such as Chapter 5 of the ICD-10 or DSM-5, diagnoses such as schizophrenia are presented as a series of categorical symptoms that are determined to either be present or absent and hence a diagnosis is assigned. Such an approach is atheoretical with regard to aetiology – the sensation of auditory hallucination for example should remain the same whether it represents a dissociated thought process or aberrant neuronal connection.
Psychodynamic understanding represents one possible aetiological theory for the symptoms of mental disorder. In this model symptoms are classified according to their underlying psychological intent – so in the psychodynamic argument the experience of psychosis has purpose, normally the relief of unbearable distress.
If normal psychic functioning represents the integration and coordination of realities then psychotic functioning represents a dispensing with, or distorting, of reality. Realities can be classified into:
- External realities – laws of behaviour observed in the physical world
- Internal realities – for example mental phenomena in the form of feelings, thoughts and words
The experience of psychosis represents a distortion of some form of reality. The, so called, normally functioning mind works to interpret experience within the framework of reality – distressing phenomena therefore lead to suffering. Psychosis provides relief from this suffering through distortion of the reality that has inflicted the distress.
Our management of distress could be seen as either a process of integration (combining and making sense of experience) or expulsion (the forcing away of experience). Our early life developmental experience – through early attachment and family life for example determines our capacity to either integrate or expel material with which we are presented.
Psychosis can therefore represent a severing of connection between the individual and reality. Their description of experience may seem strange to their audience representing as it does a form of denial of reality.
Working within this framework the aim of therapeutic intervention is to help the person to integrate and make sense of their experience in a supportive environment. This process is aided partially through careful interpretation of mental phenomena – linking back to previous experience. This process is time consuming and delicate however – confrontation of too blunt interpretation too early in the process, without the necessary preliminary work, may represent a form of re-traumatisation.
Critical Psychiatry and Global Mental Health – Pat Bracken
This talk began with a statement relating to the nature of critical thought and its role within modern psychiatry, it then moved onto discuss the implications of disseminating psychiatric thinking, as represented by technological models of psychiatric care, to communities outside of Europe and the United States.
I’ve presented my notes from this lecture below, in bullet points:
- Critical thought
- Positive, not negative, agenda
- Necessary to produce practice that is mature, rationally informed, unbiased by cynical interests
- The technological paradigm – likely the dominant current paradigm
- Ontological – mental problems are understood as emerging from faulty mechanisms
- Often imagined as biological in origin
- Faulty cognitive / emotional function
- We can model these faulty processes in causal terms
- That is independent of context
- Quantitative naturalistic paradigms are therefore placed centrally
- Technological interventions are instrumental that is they work regardless of context
- Questions relating to relationships, power etc are not neglected entirely, but are placed as of secondary importance
- Consider the ontological interpretation
- Spiritualist interpretations are seen as ignorant – need for greater psychoeducation
- Causal ontology – we can render suffering meaningful by reducing it to causal processes (Schweder – 2003)
- Kirmayer – different ontologies may recognise different agencies as having healing efficacy.
- Different causal ontologies – could be resource for sustaining us
- For example assumption that positions mental disorders alongside neurological disorders – Collins 2011, Nature 475 27-30
- Is the mind truly understandable as simply another organ of the body
- Can we use the same investigative mechanisms to study it?
- Obeyesekere – the work of culture is process of transforming painful experience into publicly accepted sets of meanings and symbols
- In studying the representations of mind is psychiatry uniquely placed in needing to address these cultural phenomena?
- Technological assumptions
- Statements such as observations of absent treatment (Patel 2011)
- Leads to assumption – stigmatising beliefs in general populations
- Can these assumptions be challenged by non-specific factors e.g in psychotherapy
- Research into temple healing – Raguram et al 2002 – BMJ
- The difference in rates of recovery between developed vs developing economies in WHO studies (c.f recent China studies in BJP)
- The moral case for exporting Western interpretation of mental disorder – Patel 2006
- Is there a more pressing case for caution?
- May there be unanticipated effects of psychiatric interpretation
The philosophy of green care – Rex Haigh
This presentation represented a summary of work conducted in the Berkshire area – developing a form of therapeutic community wherein service users worked together, after morning therapy sessions, to develop an allotment – horticultural therapy perhaps. The talk presented was positive in manner and enjoyable – unfortunately in direct contrast to a recent blog on the subject by Rex Haigh.
Imagining critical psychiatry communities in the US – Bradley Lewis
I’ve referred in previous blogs to the work of Bradley Lewis and his representations of Narrative Psychiatry. This talk reflected on the link between the natural sciences and the humanities – presenting these as polar opposites on a spectrum with varying themes including psychiatry and critical psychiatry at various points along the spectrum. Again I’ve presented my notes from the talk below:
- Reflection on “bio cultures manifesto” – Davis and Morris 2007, need to bring the body into the humanities
- Critical psychiatry – role of culture within the physical
- Science and the humanities are incomplete without the other
- Bodies are always culturally informed
- Facts are produced within a cultural space
- Suggestion of spectrum – from bioscience to humanities
- Where does critical psychiatry position in this landscape?
- Can we reach further down into the spectrum toward art / humanity
- Narrative psychiatry
- Metaphor, plot and character as key elements of narrative medicine and underpinning clinical care
- Risk of over emphasis on empathy with loss of critique role
- Varieties of psychiatric metaphor?
- Deficit vs generative models
- The artist as more sensitive than others?
- Generative – spiritual, political and creative
- Narrative psychiatry through Foucauldian analysis
- Three movements:
- How the ‘mad’ are situated within metaphor – models of madness?
- Institutions of power
- Power as shorthand for relations of power
- Cares of the self
- Foucault 1984 (Ethics of the concern for self as a practice of freedom)
- The pharmaceutical industry use narrative for their advertisement
- ‘They are not selling pills they are selling identities’
- The biomedical metaphor – is it bad? Is it monopolistic?
- The Icarus project
- Navigating boundaries of ‘dangerous gift’
The little red Alfa – trying to support someone stopping neuroleptics
This first presentation after lunch was a case presentation from a, soon to be released, book of similar cases. The thrust of the case was the importance of attending to the content of reported phenomenology during assessments – linking with the theme of psychodynamic understanding of psychosis above this case hinged on a desire for a specific object (the little red Alfa [romeo]) and the difficulties that emerged from avoidance of this desire.
A series of case presentations and discussions followed. Themes presented in these discussions included:
- The role of the mental health act in community care
- Handling tensions within clinical teams
The day ended with a discussion of the role of critical psychiatry within psychiatry in general – in particular the relationship between the critical psychiatry network and the Royal College of Psychiatry.
I thought this would be a good place to end with a couple of my own reflections from the day. I found this a useful conference on several levels. The material presented was interesting, but not particularly novel for me – I had read many of the articles and books referred to during the meeting. What was perhaps of more value to me was meeting with other individuals who, while trying to offer a good standard of psychiatric care, have run up against concerns in relation to the, predominantly biomedical stance, that the psychiatric profession occupies. I have concerns regarding this stance as I have frequently said in more detail elsewhere but often feel as if there are few others who share these concerns. I think that meeting with a group of people who share some of these beliefs, while not letting them go unchallenged was of value.
I had hoped to find a similar atmosphere at a recent medical psychotherapy conference; however, as I’ve written there was another tension in that conference regarding the provision of care. That tension was present at this conference as well but I felt it was more openly addressed and accepted.
I think that critics have a continuing positive role to play within mental health care. Challenging of long held assumptions is an act that I believe is of great value and will, I believe, ultimately lead to better care being provided overall.